What is the treatment for a patient presenting with intestinal ileus symptoms?

Management of Intestinal Ileus

The primary treatment for intestinal ileus is administering isotonic intravenous fluids such as lactated Ringer's or normal saline, with the initial rate based on the degree of dehydration, while addressing underlying causes and providing supportive care. 1

Initial Assessment and Management

• Fluid Resuscitation:

  • Begin with isotonic IV fluids (lactated Ringer's or normal saline)
  • Continue until bowel function returns and oral intake is tolerated
  • Monitor vital signs every 4 hours, track intake/output, and perform daily abdominal exams

• Nasogastric Decompression:

  • Place nasogastric tube for decompression if significant abdominal distention is present
  • Remove as soon as possible to facilitate early oral feeding when appropriate

• Correct Underlying Factors:

  • Discontinue any non-essential medications that may cause constipation
  • Correct electrolyte abnormalities (particularly potassium, magnesium)
  • Treat any underlying infections or other contributing conditions

Pharmacological Interventions

1. For Opioid-Induced Ileus:

   • Consider methylnaltrexone 0.15 mg/kg subcutaneously every other day (except in post-op ileus and mechanical bowel obstruction) 2
   • Implement opioid-sparing analgesia techniques (acetaminophen, NSAIDs if not contraindicated)

2. For Persistent Ileus:

   • Consider prokinetic agents such as metoclopramide (10-20 mg PO QID) 2
   • For colonic pseudo-obstruction: neostigmine may be effective 3

3. For Constipation Component:

   • Add and titrate bisacodyl 10-15 mg daily-TID with goal of one non-forced bowel movement every 1-2 days 2
   • Consider polyethylene glycol (1 capful/8 oz water BID), lactulose (30-60 mL BID-QID), or sorbitol (30 mL every 2 hours × 3, then as needed) 2

Nutrition Management

• Initially maintain bowel rest with NPO status
• Once bowel function begins to return (passing flatus, decreased abdominal distention):
  • Start clear liquids and advance diet as tolerated
  • Consider enteral nutrition via nasogastric or nasoenteric tube if prolonged ileus is expected
  • When advancing diet, recommend small, frequent meals (4-6 per day) rather than large meals 1

Monitoring for Complications

• Watch for signs of peritonitis: Rigid abdomen, rebound tenderness, severe pain
• Monitor for intra-abdominal hypertension: Found in up to 20% of critically ill patients 4
• Check lactate levels: Elevated levels may indicate bowel ischemia, though normal values don't exclude it 1

Special Considerations

1. Post-operative Ileus:

   • Early mobilization is crucial to stimulate bowel function 1
   • Encourage caffeine-containing drinks to stimulate colonic motor activity 1
   • Gradually increase fiber intake through fruits, vegetables, and whole grains 1

2. Inflammatory Bowel Disease-Related Ileus:

   • May require additional treatments such as corticosteroids 1

3. C. difficile-Associated Ileus:

   • Treat with appropriate antibiotics (metronidazole 500 mg PO/IV QID or vancomycin 125-500 mg PO QID for 10-14 days) 2
   • Consider rectal vancomycin for fulminant cases with ileus 1

Indications for Surgical Intervention

Surgical intervention is rarely needed for functional ileus but may be necessary if:

• Evidence of mechanical obstruction is present
• Perforation is suspected
• Patient shows signs of peritonitis
• Clinical deterioration occurs despite medical management 1

Criteria for Transfer to Higher Level of Care

Consider transfer to an acute care facility if:

• Clinical deterioration occurs
• Suspected mechanical obstruction requires surgical intervention
• Severe electrolyte abnormalities develop
• Evidence of peritonitis or sepsis emerges 1

By following this structured approach to managing intestinal ileus, clinicians can effectively address symptoms, prevent complications, and improve patient outcomes.