From the Guidelines
The treatment for intestinal obstruction (ileus) in both the small intestine and large intestine (bowel) focuses on supportive care, with initial management including bowel rest, intravenous fluid administration, and nasogastric tube placement for decompression, as recommended by the most recent guidelines 1.
Initial Management
The cornerstone of treatment is non-operative management, which is effective in approximately 70–90% of patients with adhesive small bowel obstruction (ASBO) 1. This approach includes:
- Nil per os (NPO) to rest the bowel
- Decompression using a naso-gastric tube or long intestinal tube
- Fluid resuscitation to maintain hydration and electrolyte balance
- Correction of electrolyte disturbances
- Nutritional support
- Prevention of aspiration
Duration of Non-Operative Management
The optimal duration of non-operative treatment is subject to debate, but most authors consider a 72-h period as safe and appropriate 1. Continuing non-operative treatment for more than 72 h in cases with persistent high output from a decompression tube, but no other signs of clinical deterioration, remains subject to debate.
Surgical Intervention
Surgical intervention is rarely needed for uncomplicated ileus but may be necessary if mechanical obstruction cannot be ruled out or if complications develop 1. For malignant left-sided large bowel obstruction, self-expanding colonic endoluminal stents have been successfully used as a non-invasive technique to relieve obstruction, allowing surgical resection to be performed on an elective rather than emergency basis 1.
Medications and Nutrition
Medications that may help include prokinetic agents such as metoclopramide, erythromycin, or neostigmine in select cases 1. Alvimopan may be used for postoperative ileus. Nutrition should be reintroduced gradually once bowel sounds return and flatus or bowel movements occur, starting with clear liquids and advancing as tolerated.
Key Considerations
- Early ambulation is encouraged to stimulate bowel function
- Pain management should utilize non-opioid medications when possible, as opioids can worsen ileus
- The underlying cause of ileus must be identified and treated, whether it's electrolyte abnormalities, infection, or medication side effects
- Nasogastric suction can be diagnostically useful to analyze gastric contents and therapeutically important to prevent aspiration pneumonia and decompress the proximal bowel 1
From the Research
Treatment for Intestinal Obstruction (Ileus)
The treatment for intestinal obstruction (ileus) in both the small intestine and large intestine (bowel) involves various approaches, including:
- Supportive measures such as intravenous rehydration, correction of electrolyte abnormalities, and discontinuation of antikinetic drugs 2
- Treatment of underlying conditions that may be contributing to the ileus 3, 2
- Stimulation of gastric and intestinal motility 3
- Nutritional support, including early enteral nutrition (EEN) 4
- Pharmacologic interventions, such as neostigmine for colonic pseudo-obstruction 2
- Colonoscopic decompression for colonic pseudo-obstruction 2
- Surgical intervention, such as decompressive laparotomy, in severe cases like abdominal compartment syndrome 3
Pharmacologic Agents
Various pharmacologic agents have been investigated for the treatment of ileus, including:
- Metoclopramide: not effective in expediting the resolution of ileus 4
- Erythromycin: not effective in improving postoperative bowel function 5, 4
- Neostigmine: effective for pharmacologic colonic decompression in colonic pseudo-obstruction 2
- Cisapride: appears to hold promise for patients with colonic motility disorders, but its use is not widely recommended due to potential side effects 6
Nutritional Support
Early enteral nutrition (EEN) has been shown to facilitate the return of normal bowel function, achieve enteral nutrition goals, and reduce hospital length of stay in patients with ileus 4