Treatment of Ileus Pattern with Gaseous Distension
The management of ileus with gaseous distension should focus on bowel rest, nasogastric decompression, fluid resuscitation, electrolyte correction, and addressing the underlying cause, with pharmacological interventions like metoclopramide considered for stimulating upper GI motility. 1
Initial Management
Decompression and Fluid Management
- Insert a nasogastric tube for gastric decompression to relieve distension and prevent vomiting
- Consider a venting gastrostomy (ideally over 20 French gauge) for persistent symptoms 2
- Provide intravenous fluids (lactated Ringer's or normal saline) to correct dehydration
- Monitor and correct electrolyte abnormalities, particularly potassium, magnesium, and sodium 1
- Avoid fluid overload, limiting weight gain to <3kg 1
Diagnostic Evaluation
- Obtain plain abdominal radiographs to assess for gaseous distension pattern
- Consider CT scan with IV contrast to differentiate between functional ileus and mechanical obstruction 1
- Complete blood count to assess for leukocytosis
- Check electrolytes, BUN/creatinine, CRP, and lactate levels 1
Pharmacological Interventions
First-line Medications
- Metoclopramide: Consider for stimulating upper GI motility 1, 3
- Can be administered IV for better absorption in ileus
- Particularly useful for upper GI motility issues
- FDA-approved for facilitating small bowel intubation 3
Additional Medication Options
Neostigmine: Consider for established colonic ileus not responding to other measures 1
- Start with low dose and titrate as needed
- Contraindicated in patients with cardiac issues
- Monitor for bradycardia and increased secretions
Antibiotics for bacterial overgrowth:
Special Situations
- For opioid-induced ileus:
Nutritional Support
- Early tube feeding (within 24 hours) if oral nutrition is inadequate 1
- Enteral nutrition is preferred over parenteral nutrition when possible 1
- Consider nasogastric or nasoenteric feeding if the patient can tolerate it 1
- Reserve parenteral nutrition for cases with significant malnutrition or when enteral nutrition fails 1
Non-pharmacological Approaches
- Early and regular mobilization to stimulate bowel function 1
- Position patient with head of bed elevated 30-45 degrees to reduce aspiration risk 1
- Consider chewing gum to potentially shorten time to flatus and first bowel movement 1
- Simple measures such as reducing fiber in diet can reduce abdominal distension 2
- Low FODMAP diets may help but should be avoided in malnourished patients 2
Monitoring and Complications
- Monitor for resolution of ileus by assessing abdominal distention, bowel sounds, and passage of flatus/stool 1
- Watch for intra-abdominal hypertension, which occurs in up to 20% of critically ill patients 4
- Monitor for signs of peritonitis which may indicate perforation or ischemia 2
- For persistent symptoms, consider colonic tube placement after decompressive colonoscopy 4
Surgical Considerations
- 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 5
Pitfalls and Caveats
- The absence of peritonitis does not rule out bowel ischemia; check lactate levels but note that normal values cannot exclude ischemia 2, 1
- Avoid opioids when possible as they can worsen ileus 1
- If using metronidazole long-term, monitor for peripheral neuropathy 2
- With ciprofloxacin, watch for tendonitis and rupture 2
- Consider C. difficile testing if infectious etiology is suspected, especially with antibiotic use 1
By following this structured approach to treating ileus with gaseous distension, you can effectively manage symptoms while addressing the underlying cause and preventing complications.