What is the treatment for generalized ileus?

Management of Generalized Ileus

The treatment of generalized ileus requires a comprehensive approach including nasogastric decompression, intravenous fluid resuscitation, correction of electrolyte abnormalities, bowel rest, and early mobilization, while avoiding medications that worsen ileus such as anticholinergics, antidiarrheals, and opioids. 1

Initial Management

Gastrointestinal Decompression

• Place a nasogastric tube for decompression when there is significant abdominal distention or vomiting 1, 2
• Avoid routine nasogastric decompression if not needed, as this may prolong ileus 2

Fluid and Electrolyte Management

• Administer isotonic intravenous fluids (lactated Ringer's or normal saline) 2, 1
• For severe dehydration, continue IV rehydration until pulse, perfusion, and mental status normalize 2
• Target neutral fluid balance after initial resuscitation to avoid fluid overload, which can worsen ileus 2, 1, 3
• Correct electrolyte abnormalities, particularly potassium (add 20 mEq/L potassium chloride to IV fluids) 2, 1

Medication Management

Medications to Avoid

• Anticholinergic agents (worsen decreased GI motility) 1
• Antidiarrheal medications, especially opioid-based agents like loperamide 1
• Minimize opioid analgesics as they significantly worsen ileus 1, 4

Potential Pharmacologic Interventions

• Consider prokinetic agents in selected cases:
  • Metoclopramide (10-20 mg PO QID) may help stimulate upper GI motility 2, 5
  • Erythromycin (IV) may be used as a motilin agonist 6
  • Neostigmine may be considered for established colonic ileus not responding to other measures 1
• For opioid-induced constipation, consider methylnaltrexone (0.15 mg/kg SC every other day) 2
• Alvimopan (μ-opioid receptor antagonist) can accelerate GI recovery in postoperative ileus when opioid analgesia is used 2

Pain Management

• Use thoracic epidural analgesia when possible for postoperative ileus, as it is highly effective at preventing and treating ileus 2, 1
• Implement opioid-sparing multimodal analgesia techniques 1, 4

Mobilization and Nutrition

Mobilization

• Early mobilization is strongly recommended to stimulate bowel function 2, 1
• Assist patients to mobilize as soon as possible after surgery 1

Nutrition Management

• Maintain bowel rest initially until bowel function returns 1
• Once bowel sounds return, start oral intake with clear liquids and advance as tolerated 1
• Consider early tube feeding (within 24 hours) if oral intake will be inadequate for more than 7 days 2
• If enteral feeding is contraindicated, initiate parenteral nutrition 2, 1

Additional Measures

• Chewing gum may help stimulate bowel function 2
• Consider laxatives such as bisacodyl (10-15 mg daily-TID) or magnesium oxide to promote bowel function 2

Special Considerations

• For ileus due to Clostridium difficile infection, treat with appropriate antibiotics (metronidazole or vancomycin) 2
• For ileus with suspected mechanical obstruction, surgical consultation is warranted 7
• For patients with neutropenia and ileus, administer broad-spectrum antibiotics 1

Monitoring

• Perform serial abdominal examinations to assess for distention, tenderness, and return of bowel sounds 1
• Monitor for complications including abdominal compartment syndrome, which may require surgical decompression 3

The management approach should be tailored based on the underlying cause of ileus, with mechanical obstruction requiring potential surgical intervention while functional ileus typically responds to conservative measures.