What is the treatment for ileus?

Treatment of Ileus

The treatment of ileus requires a multifaceted approach including fluid resuscitation with isotonic intravenous fluids, bowel rest, nasogastric tube decompression avoidance, early mobilization, and minimizing opioid use. 1

Initial Management

Fluid and Electrolyte Management

• Administer isotonic intravenous fluids (lactated Ringer's or normal saline) for severe dehydration, shock, altered mental status, or when oral rehydration fails 1
• Continue IV rehydration until:
  • Pulse, perfusion, and mental status normalize
  • Patient awakens
  • No risk factors for aspiration remain
  • No evidence of ileus persists 1
• Monitor and correct electrolyte abnormalities, especially magnesium 2
• Target fluid volume of 2200-4000 mL/day 2

Bowel Rest and Decompression

• Avoid routine nasogastric tube decompression as it may prolong ileus duration 1
• If nasogastric tube is placed for severe symptoms, remove as soon as possible without clamping trials 3

Pharmacological Management

Medications to Avoid

• Discontinue medications that worsen ileus:
  • Opioids (highest priority to discontinue) 1, 2
  • Anticholinergics 2
  • Other motility-inhibiting drugs 4

Prokinetic Agents

• Consider metoclopramide to stimulate upper GI motility 2
• Neostigmine (anticholinesterase) may be effective for colonic pseudo-obstruction 4
• For postoperative ileus:
  • Oral magnesium oxide may promote bowel function 1
  • Bisacodyl (10 mg orally twice daily) can improve intestinal function 1
  • Alvimopan (μ-opioid receptor antagonist) can accelerate GI recovery when opioid analgesia is used 1

Nutritional Support

Oral/Enteral Nutrition

• Early oral nutrition should be encouraged once signs of resolving ileus appear 1, 2
• Start with small, frequent meals with low-fat, low-fiber content 2
• For patients unable to tolerate oral intake:
  • Initiate tube feeding within 24 hours if oral intake will be inadequate (<50% of caloric requirement) for more than 7 days 1
  • Start with small volumes (10-20 mL/hr) and gradually increase as tolerated 2

Parenteral Nutrition

• Consider parenteral nutrition if enteral feeding is contraindicated (intestinal obstruction, severe ileus, sepsis, intestinal ischemia, high output fistulae) 1
• Transition to enteral or oral nutrition as gastrointestinal function recovers 1

Non-Pharmacological Interventions

Mobilization

• Implement early and regular mobilization to stimulate bowel function 1, 2
• Position patient with head of bed elevated 30-45 degrees to reduce aspiration risk 2

Other Interventions

• Chewing gum may have a positive effect on postoperative ileus duration 1
• Consider water-soluble contrast agents for treatment of persistent ileus 1

Monitoring for Resolution

• Assess for:
  • Decreased abdominal distention
  • Return of bowel sounds
  • Passage of flatus or stool 2
  • Tolerance of oral intake

Special Considerations

Surgical Intervention

• Consider surgical consultation for:
  • Evidence of bowel perforation
  • Abdominal compartment syndrome
  • Clinical deterioration despite aggressive supportive measures
  • Persistent gastrointestinal bleeding 2
  • Mechanical obstruction that fails to resolve with conservative management 5

Postoperative Ileus Prevention

• Use mid-thoracic epidural analgesia when possible 1
• Prefer laparoscopic over open surgical techniques 1
• Avoid fluid overload (limit weight gain to <3kg by postoperative day 3) 1
• Use opioid-sparing analgesia 1

By implementing this comprehensive approach to ileus management, focusing on fluid resuscitation, minimizing factors that worsen ileus, and providing appropriate nutritional support, most cases can be successfully treated without surgical intervention 5.