What is the treatment and disposition for a 14-year-old female with ileus?

Management of Ileus in a 14-Year-Old Female

The primary treatment for ileus in a 14-year-old female includes bowel rest, nasogastric decompression, intravenous fluid resuscitation, and correction of electrolyte abnormalities, with early mobilization once stabilized. 1

Initial Assessment and Management

Diagnostic Confirmation

• Obtain abdominal radiographs to confirm ileus and exclude mechanical obstruction
• Consider CT scan if mechanical obstruction is suspected or if clinical condition deteriorates 1
• Assess for signs of dehydration, electrolyte abnormalities, and systemic inflammatory response

Immediate Interventions

1. Nasogastric Tube Placement

   • Place a nasogastric tube for decompression when there is significant abdominal distention or vomiting 1
   • This helps reduce abdominal distention and prevents aspiration

2. Intravenous Fluid Resuscitation

   • Administer isotonic fluids (lactated Ringer's or normal saline) 1
   • Correct electrolyte abnormalities, particularly potassium, sodium, and magnesium imbalances
   • Target neutral fluid balance after initial resuscitation to avoid fluid overload 1

3. Bowel Rest

   • Maintain nothing by mouth (NPO) status initially until bowel function returns 1
   • Monitor for return of bowel sounds, passage of flatus, and bowel movements

Pharmacological Management

Prokinetic Agents

• Consider metoclopramide 10 mg IV every 6 hours to stimulate upper GI motility 1, 2
  • For pediatric patients 14 years of age: 10 mg metoclopramide base 2
  • Monitor for extrapyramidal side effects
  • If dystonic reactions occur, administer diphenhydramine 50 mg IM 2

Antibiotics

• If bacterial overgrowth is suspected:
  • Consider oral antibiotics such as metronidazole 500 mg three times daily 3
  • Alternative options include amoxicillin-clavulanic acid, ciprofloxacin, or rifaximin 3
  • For C. difficile infection (if suspected): vancomycin 125 mg orally four times daily for 10 days 3

Medications to Avoid

• Discontinue opioids if possible, as they worsen ileus 3
• Avoid anticholinergic agents, which further decrease GI motility 1

Nutritional Support

Reintroduction of Oral Intake

• Once bowel function returns, start with clear liquids and advance as tolerated 1
• Gastric motility may be less impaired for liquids than solids 3

Enteral Nutrition Considerations

• For prolonged ileus (>7 days), consider:
  • Enteral nutrition via nasojejunal tube to bypass the stomach 1
  • Frequent small meals with low-fat, low-fiber content once oral intake is resumed 3

Parenteral Nutrition

• If enteral feeding fails or is contraindicated, initiate parenteral nutrition to maintain nutritional status 3
• This is particularly important if the patient is malnourished or at risk of malnutrition

Non-Pharmacological Interventions

Early Mobilization

• Encourage early and progressive mobilization to stimulate bowel function 1
• Start with sitting up in bed, then progress to standing and walking as tolerated

Monitoring

• Monitor for signs of bacterial translocation and systemic inflammatory response syndrome 1, 4
• Assess intra-abdominal pressure if abdominal distention is severe 4
• Watch for complications such as aspiration pneumonia, malnutrition, and prolonged hospital stay 5

Disposition

Hospital Admission

• Admit to inpatient pediatric service for monitoring and management
• Consider transfer to pediatric surgical service if:
  • Evidence of bowel perforation
  • Development of abdominal compartment syndrome
  • Clinical deterioration despite aggressive supportive measures
  • Persistent gastrointestinal bleeding 1

Discharge Criteria

• Resolution of abdominal distention
• Return of normal bowel function (passing flatus and stool)
• Tolerance of oral diet
• Normal vital signs and laboratory values

Special Considerations

Underlying Causes

• Investigate and address potential underlying causes:
  • Recent surgery or trauma
  • Electrolyte abnormalities
  • Medications (especially opioids)
  • Infections (including C. difficile)

Prevention of Recurrence

• Implement opioid-sparing multimodal analgesia techniques 1
• Continue early mobilization after discharge
• Maintain adequate hydration
• Avoid medications known to impair intestinal motility

By following this comprehensive approach to managing ileus in a 14-year-old female, you can optimize outcomes and minimize complications while addressing the underlying cause of the condition.