What is the management for functional ileus?

Management of Functional Ileus

The management of functional ileus should focus on supportive care, fluid resuscitation, discontinuation of medications that worsen ileus (especially opioids), early mobilization, and targeted pharmacologic interventions to stimulate bowel function. 1

Initial Assessment and Supportive Measures

• Fluid Resuscitation:

  • Administer isotonic intravenous fluids (lactated Ringer's or normal saline) for dehydration
  • Avoid fluid overload (limit weight gain to <3kg) to prevent worsening of ileus 1
  • Monitor and correct electrolyte imbalances, especially magnesium 1

• Nasogastric Decompression:

  • Avoid routine nasogastric tube placement as it may prolong ileus 2
  • Reserve nasogastric decompression for patients with significant abdominal distention, vomiting, or respiratory compromise

Medication Management

• Discontinue Contributing Medications:

  • Stop opioids as highest priority (switch to non-opioid analgesics) 1
  • Avoid anticholinergic agents which worsen ileus 1
  • Consider opioid-sparing analgesia with acetaminophen/paracetamol and NSAIDs if not contraindicated 1

• Prokinetic Agents:

  • Consider metoclopramide to stimulate upper GI motility 1
  • Oral magnesium oxide may promote bowel function 2
  • Bisacodyl (10 mg orally twice daily) can improve intestinal function 2
  • Alvimopan (μ-opioid receptor antagonist) accelerates GI recovery when opioid analgesia is used 2, 1

Nutrition Management

• Early Feeding:
  • Encourage early oral nutrition once signs of resolving ileus appear 1
  • Avoid prolonged fasting which can worsen ileus 2
  • Consider tube feeding within 24 hours if oral intake will be inadequate 1
  • Reserve parenteral nutrition for cases with significant malnutrition or when enteral nutrition fails 1

Non-Pharmacological Interventions

• Early Mobilization:

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

• Mechanical Stimulation:

  • Chewing gum has a positive effect on postoperative ileus duration 2, 1

Special Considerations

• Epidural Analgesia:

  • Mid-thoracic epidural analgesia is highly effective at preventing postoperative ileus 2
  • Thoracic epidural analgesia (TEA) has been associated with lower incidence of paralytic ileus, improved intestinal blood flow, and reduction of opioid use 2

• Surgical Approach:

  • Laparoscopic surgery leads to faster return of bowel function compared with open surgery 2

Monitoring for Resolution

• Monitor for:
  • Decreased abdominal distention
  • Return of bowel sounds
  • Passage of flatus/stool
  • Tolerance of oral intake 1

Common Pitfalls to Avoid

1. Overuse of opioids - Even small doses can significantly worsen ileus
2. Excessive fluid administration - Can exacerbate bowel wall edema and worsen ileus
3. Prolonged fasting - Delays recovery of normal bowel function
4. Delayed mobilization - Contributes to prolonged ileus
5. Failure to distinguish between functional ileus and mechanical obstruction - Different management approaches are required

By implementing these evidence-based strategies, functional ileus can be effectively managed in most patients, minimizing complications and reducing recovery time.