How to manage an ileus?

Management of Ileus

A multifaceted approach including minimally invasive surgery, optimized fluid management, opioid-sparing analgesia, early mobilization, early postoperative food intake, laxative administration, and omission/early removal of nasogastric tubes should be used to treat ileus. 1

Initial Assessment and Management

Identify and Address Underlying Causes

• Exclude other causes of ileus such as:
  • Intra-abdominal sepsis
  • Partial/intermittent bowel obstruction
  • Enteritis (e.g., Clostridium or Salmonella)
  • Recurrent disease (e.g., Crohn's disease)
  • Abrupt cessation of medications (e.g., steroids or opiates) 2

Immediate Interventions

1. Fluid and Electrolyte Management:

   • Correct dehydration with intravenous normal saline while keeping the patient nil by mouth for 24-48 hours 2
   • Monitor and correct electrolytes, particularly sodium and potassium 1
   • Avoid fluid overload; limit weight gain to <3kg by postoperative day 3 1

2. Nasogastric Decompression:

   • Consider nasogastric tube placement only for patients with significant nausea or vomiting 1
   • Remove nasogastric tubes as soon as possible to promote early oral feeding 1

Pain Management

• Implement opioid-sparing analgesia:

  • Use thoracic epidural analgesia for 48-72 hours when possible
  • Substitute opioids with regular acetaminophen/paracetamol
  • Add NSAIDs if not contraindicated
  • Consider alternatives for minimally-invasive procedures: intrathecal analgesia, intravenous lidocaine, locoregional blocks 1

• Consider alvimopan (μ-opioid receptor antagonist) to accelerate GI recovery when opioid analgesia is necessary 1

Nutritional Support

1. Early Oral Feeding:

   • Promote early oral feeding as soon as the patient is lucid 1
   • Consider a progressive diet approach

2. For Patients Unable to Tolerate Oral Intake:

   • Prefer enteral feeding over total parenteral nutrition due to fewer side effects and lower expense 1
   • Consider parenteral nutrition when oral intake will be inadequate (<50% of caloric requirement) for more than 7 days 1

Pharmacological Interventions

1. Motility Agents:

   • Metoclopramide may be used to stimulate gastric emptying and intestinal transit 1, 3
   • Consider loperamide 2-8 mg before food for patients with high output ileostomy 2
   • Oral magnesium oxide and bisacodyl (10 mg orally twice daily) can promote bowel function 1

2. For Persistent Ileus:

   • Consider water-soluble contrast agents and neostigmine for established postoperative ileus 1
   • For ileus with bacterial overgrowth, rifaximin may be considered 1
   • If high output "secretory" output (>3L/24h), consider drugs that reduce gastric acid secretion (H2 antagonists or proton pump inhibitors) or octreotide 2

Specific Management for High-Output Ileostomy/Jejunostomy

• Reduce oral hypotonic fluids to 500 ml/day 2
• Provide glucose/saline solution to sip (sodium concentration at least 90 mmol/l) 2
• Add sodium chloride to liquid feeds to make sodium concentration near 100 mmol/l 2
• Separate solids and liquids (no drink for half an hour before or after food) 2
• For ileostomy patients:
  • Increase sodium intake by adding 0.5-1 teaspoon of salt per day 2
  • Increase potassium-rich foods if serum potassium is low 2
  • Encourage 2-2.5 liters of fluids per day, preferring isotonic drinks 2

Additional Measures

• Implement early and regular mobilization to stimulate bowel function 1
• Position the patient with head of bed elevated 30-45 degrees to reduce aspiration risk 1
• Monitor for resolution of ileus by assessing abdominal distention, bowel sounds, and passage of flatus/stool 1
• Consider chewing gum as it may shorten time to flatus and first bowel movement 1

Management of Complications

• For abdominal compartment syndrome (IAP above 20-25 mmHg with systemic consequences), consider decompressive laparotomy 4
• For prolonged ileus (>7 days), consider multidisciplinary team involvement including gastroenterologist, pain specialist, and nutritionist 1, 5

Common Pitfalls to Avoid

• Avoid routine nasogastric tube placement unless necessary for symptomatic relief 1
• Avoid antiperistaltic agents and prolonged bowel rest 1
• Avoid excessive crystalloid administration (≥2 liters) as it may worsen ileus 1
• Do not delay surgical intervention if complete obstruction or strangulation is suspected 6