What is the treatment for ileus?

Treatment of Ileus

The initial management of ileus should focus on bowel rest, nasogastric decompression, fluid resuscitation, electrolyte correction, and addressing the underlying cause, while pharmacological interventions like metoclopramide can be considered for stimulating upper GI motility. 1

Initial Assessment and Management

Diagnostic Evaluation

• Assess for abdominal distention, bowel sounds, passage of flatus or stool, nausea, vomiting, and weight gain 1
• Consider CT scan of abdomen and pelvis to differentiate between functional ileus and mechanical obstruction (nearly 100% sensitivity and specificity) 1
• Plain abdominal radiography may show dilated bowel loops and air-fluid levels but has limited diagnostic value (60-70% sensitivity) 1
• Laboratory tests to consider:
  • Complete blood count (for leukocytosis)
  • Electrolytes, BUN/creatinine (for dehydration and imbalances)
  • CRP and lactate (for inflammation or ischemia)
  • Stool studies if infectious etiology is suspected 1

Conservative Management

1. Bowel Rest and Decompression

   • Nasogastric tube placement to decompress the stomach and prevent vomiting
   • Monitor output from nasogastric tube 1

2. Fluid Resuscitation and Electrolyte Correction

   • Administer isotonic intravenous fluids (lactated Ringer's or normal saline)
   • Monitor urine output with Foley catheter in severe cases
   • Avoid fluid overload (limit weight gain to <3kg) 1
   • Correct electrolyte abnormalities, particularly potassium, magnesium, and sodium 1

3. Nutrition Management

   • Early tube feeding (within 24 hours) if oral nutrition is inadequate
   • Enteral nutrition is preferred over parenteral nutrition when possible
   • Consider parenteral nutrition for cases with significant malnutrition or when enteral nutrition fails 1

Pharmacological Interventions

1. Prokinetic Agents

   • Metoclopramide can be used to stimulate upper GI motility 1, 2
   • Note: FDA-approved indications for metoclopramide include diabetic gastroparesis, prevention of chemotherapy-induced nausea/vomiting, and facilitation of small bowel intubation 2

2. Opioid Antagonists

   • Consider methylnaltrexone for opioid-induced constipation (except in post-op ileus and mechanical obstruction)
   • Alvimopan (μ-opioid receptor antagonist) may accelerate GI recovery when opioid analgesia is used 1

3. Other Medications

   • Neostigmine may be considered for established colonic ileus not responding to other measures
   • Rifaximin may help with prolonged ileus with bacterial overgrowth 1

Special Considerations

Inflammatory Bowel Disease-Associated Ileus

• For ileus associated with inflammatory bowel disease, additional treatments such as corticosteroids may be needed 3, 1
• Intravenous steroids (hydrocortisone 400 mg/day or methylprednisolone 60 mg/day) are appropriate for patients with severe disease 3
• Concomitant intravenous metronidazole may be advisable when it's difficult to distinguish between active disease and septic complications 3

Complications and Monitoring

• Monitor for intra-abdominal hypertension, which occurs in up to 20% of critically ill patients 4
• Position patient with head of bed elevated 30-45 degrees to reduce aspiration risk 1
• Watch for signs of resolution: improved abdominal distention, return of bowel sounds, passage of flatus/stool 1

Non-Pharmacological Interventions

• Early mobilization to stimulate bowel function 1, 5
• Consider chewing gum, which may shorten time to flatus and first bowel movement 1
• Implement opioid-sparing analgesia strategies when possible 1, 6

When to Consider Surgical Intervention

• Surgical intervention is rarely needed for functional ileus but may be necessary if:
  • Evidence of mechanical obstruction exists
  • Perforation is suspected
  • Patient shows signs of peritonitis
  • Clinical deterioration occurs despite medical management 1, 7
• In abdominal compartment syndrome (IAP above 20-25 mmHg with systemic consequences), decompressive laparotomy may be required 4

Common Pitfalls and Caveats

• Failure to distinguish between functional and mechanical ileus can lead to inappropriate management
• Delayed recognition of abdominal compartment syndrome can result in multi-organ dysfunction 4
• Overuse of opioid analgesics can worsen ileus 5, 6
• Inadequate fluid resuscitation or excessive fluid administration can both negatively impact outcomes 1

By following this structured approach to ileus management, focusing on identifying the underlying cause while providing supportive care, most cases can be successfully resolved without surgical intervention.