What is the recommended treatment for ileus?

Management of Ileus

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

Initial Management

• Fluid Resuscitation:

  • Administer isotonic intravenous fluids (lactated Ringer's or normal saline) for dehydration, shock, or altered mental status 2, 1
  • Continue IV rehydration until pulse, perfusion, and mental status normalize 2
  • Monitor for fluid overload (limit weight gain to <3kg) and electrolyte imbalances, especially magnesium 1

• Bowel Rest and Decompression:

  • Avoid routine nasogastric tube decompression as it may prolong ileus duration 1
  • Only use nasogastric decompression selectively in cases of significant abdominal distention or vomiting

Medication Management

• Discontinue Contributing Medications:

  • Highest priority: discontinue opioids which worsen ileus 1
  • Substitute with non-opioid analgesics:
    • Regular acetaminophen/paracetamol
    • NSAIDs if not contraindicated
  • Avoid anticholinergic agents 1

• Prokinetic Agents:

  • Consider metoclopramide to stimulate upper GI motility, with dosages adjusted based on renal function 1
  • For postoperative ileus: alvimopan (μ-opioid receptor antagonist) can accelerate GI recovery when opioid analgesia is used 1

Nutritional Support

• Feeding Approach:
  • Encourage early oral nutrition once signs of resolving ileus appear 1
  • If oral intake will be inadequate (<50% of caloric requirement) for more than 7 days, initiate tube feeding within 24 hours 1
  • Consider parenteral nutrition only if enteral feeding is contraindicated (intestinal obstruction, severe ileus, sepsis, intestinal ischemia) 1
  • When starting enteral nutrition, begin with small volumes (10-20 mL/h) and gradually increase as tolerated 1

Additional Interventions

• Early Mobilization:

  • Implement early and regular mobilization to stimulate bowel function 1, 3
  • Position patient with head of bed elevated 30-45 degrees to reduce aspiration risk 1

• Adjunctive Measures:

  • Oral magnesium oxide may promote bowel function 1
  • Bisacodyl (10 mg orally twice daily) can improve intestinal function 1
  • 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:
  • Reduction in abdominal distention
  • Return of normal bowel sounds
  • Passage of flatus or stool 1
  • Tolerance of oral intake

Special Considerations

• Surgical Management:

  • Surgery is indicated only if complete mechanical obstruction or strangulation is suspected 4
  • Before any surgical intervention, restore fluid and electrolyte balance 4

• Postoperative Ileus:

  • Use mid-thoracic epidural analgesia when possible 1
  • Prefer laparoscopic over open surgical techniques to reduce ileus risk 1

Caution: Antimotility drugs (e.g., loperamide) should not be given to children <18 years of age with acute diarrhea and should be avoided in cases where toxic megacolon may result 2.

By following this comprehensive approach to ileus management, focusing on fluid resuscitation, minimizing opioids, early mobilization, and appropriate nutritional support, most cases of ileus can be effectively managed without surgical intervention.