What is the management plan for a patient with ileus?

Management of Ileus

The management of ileus requires a multifaceted approach including fluid resuscitation, bowel rest, nasogastric decompression, correction of electrolyte abnormalities, minimization of opioids, early mobilization, and consideration of prokinetic agents. 1

Diagnosis and Initial Assessment

• Confirm ileus diagnosis with abdominal radiographs to exclude mechanical obstruction
• Consider CT scan if mechanical obstruction is suspected or if clinical condition deteriorates
• Test stool for blood, fecal leukocytes, C. difficile, and enteric pathogens 2, 1
• Obtain complete blood count to assess for leukocytosis or leukopenia
• Monitor for signs of bacterial translocation and systemic inflammatory response syndrome 3

Fluid and Electrolyte Management

Hydration

• For mild to moderate dehydration: Reduced osmolarity oral rehydration solution (ORS) as first-line therapy 2
• For severe dehydration or ileus: Isotonic intravenous fluids (lactated Ringer's or normal saline) 2, 1
• Continue intravenous rehydration until pulse, perfusion, and mental status normalize and patient has no evidence of ileus 2

Electrolytes

• Regularly evaluate and correct electrolyte abnormalities, particularly potassium, sodium, and magnesium 1, 4
• Target neutral fluid balance after initial resuscitation to avoid fluid overload, which can worsen ileus 1

Gastrointestinal Management

Decompression

• Place nasogastric tube for decompression when there is significant abdominal distention or vomiting 1
• Consider colonic tube placement after decompressive colonoscopy for reducing intestinal dilatation in severe cases 3

Nutrition

• For short-term ileus: NPO (nothing by mouth) until resolution of symptoms
• For prolonged ileus (>7 days): Consider enteral nutrition via nasojejunal tube 2, 1
• If enteral feeding is contraindicated or fails, initiate parenteral nutrition 2, 1
• When resuming oral intake:
  • Start with clear liquids (gastric motility may be less impaired for liquids than solids) 1
  • Progress to small, frequent meals with low-fat, low-fiber content 1
  • Resume age-appropriate diet during or immediately after rehydration 1

Medication Management

Analgesics

• Review and modify analgesic prescription:
  • Wean opioids as they worsen ileus 1, 4
  • Substitute with regular paracetamol/acetaminophen
  • Add NSAIDs if not contraindicated
  • Consider tramadol as needed 4

Prokinetic Agents

• Consider metoclopramide 10-20 mg PO QID to stimulate upper GI motility 1
• For established colonic ileus not responding to other measures, consider neostigmine (under close monitoring) 1

Antibiotics

• If bacterial overgrowth is suspected: metronidazole 500 mg three times daily 1
• For C. difficile infection: vancomycin 125 mg orally four times daily for 10 days 1

Additional Interventions

Mobilization

• Implement early and regular mobilization to stimulate bowel function 2, 1
• This is a key component of ERAS protocols to minimize postoperative ileus 2

Surgical Considerations

• Surgical consultation if:
  • Evidence of bowel perforation
  • Development of abdominal compartment syndrome
  • Clinical deterioration despite aggressive supportive measures
  • Persistent gastrointestinal bleeding 1
• For abdominal compartment syndrome: decompressive laparotomy may be necessary 3

Monitoring and Follow-up

• Monitor abdominal distention, bowel sounds, and passage of flatus/stool
• Watch for complications such as aspiration pneumonia, malnutrition, and prolonged hospital stay 1
• Monitor intra-abdominal pressure if abdominal compartment syndrome is suspected 3
• Reassess need for continued interventions daily

By following this comprehensive approach to ileus management, focusing on fluid resuscitation, bowel rest, medication management, and early mobilization, most cases will resolve with conservative management.