What is the management for ileus?

Management of Ileus

The management of ileus should focus on bowel rest, fluid resuscitation, electrolyte correction, nasogastric decompression, and avoidance of opioids, with early mobilization and careful monitoring until bowel function returns. 1

Initial Assessment and Supportive Care

Decompression

• Insert a nasogastric tube for suction to decompress the proximal bowel, prevent aspiration pneumonia, and reduce vomiting 1
• In severe cases, venting gastrostomy or ostomy may be considered to decompress dilated segments, though these carry risks of leakage and infection 2

Fluid Management

• Administer isotonic IV fluids (lactated Ringer's or normal saline) based on degree of dehydration 1
• Avoid fluid overload as excessive IV fluids can worsen ileus 1
• Monitor fluid balance with a goal of adequate central venous pressure and urine output >0.5 mL/kg/h 1

Electrolyte Correction

• Monitor and correct electrolyte imbalances, particularly potassium, magnesium, and sodium 1
• Regular laboratory monitoring is essential as electrolyte abnormalities can worsen ileus

Pharmacological Management

Pain Management

• Thoracic epidural analgesia is the optimal approach for pain control as it effectively prevents and treats postoperative ileus while providing superior analgesia compared to opioid-based regimens 1
• Use opioid-sparing strategies:
  • Acetaminophen/Paracetamol (1g IV every 6 hours)
  • Nefopam (20mg IV) as an opioid-sparing agent with no detrimental effects on intestinal motility 1
  • If opioids must be used, consider Alvimopan (a peripherally acting μ-opioid receptor antagonist) to help prevent opioid-induced constipation 1

Prokinetic Agents

• Consider metoclopramide (10-20 mg PO QID) to stimulate upper GI motility, although evidence for its effectiveness in ileus is limited 1, 3
• The Eastern Association for the Surgery of Trauma found that neither metoclopramide nor erythromycin were effective in expediting the resolution of ileus 3

Management of Bacterial Overgrowth

• For bacterial overgrowth causing diarrhea, consider:
  • Rifaximin (often first choice if available)
  • Alternating courses of antibiotics such as amoxycillin-clavulanic acid, metronidazole, ciprofloxacin, or non-absorbable antibiotics 2
  • Be vigilant for side effects with long-term use (e.g., peripheral neuropathy with metronidazole, tendonitis with ciprofloxacin) 2

Nutritional Support

• Early enteral nutrition (EEN) is strongly recommended to expedite resolution of ileus, facilitate return of normal bowel function, and reduce hospital length of stay 1, 3
• For patients who can tolerate oral intake:
  • Consider liquid feeds as gastric motility may be less deranged for liquids than solids 2
  • Implement frequent small meals with low-fat, low-fiber content 2
• Monitor for micronutrient deficiencies, particularly iron, vitamin B12, and fat-soluble vitamins 2

Additional Interventions

Mobilization

• Early and regular mobilization is crucial to stimulate bowel function 1
• Implement progressive mobilization as tolerated by the patient

Monitoring

• Perform daily abdominal examinations to assess for:
  • Return of bowel sounds
  • Reduction in abdominal distention
  • Passage of flatus or stool 1
• Monitor vital signs every 4 hours and track intake and output 1
• Be vigilant for intra-abdominal hypertension, which occurs in up to 20% of critically ill patients 1, 4

Special Considerations

Surgical Intervention

• Surgical intervention is rarely needed for functional ileus but may be necessary if:
  • Evidence of mechanical obstruction emerges
  • Perforation is suspected
  • Patient shows signs of peritonitis
  • Clinical deterioration occurs despite medical management 1

Complications to Watch For

• Abdominal compartment syndrome (IAP above 20-25 mmHg with systemic consequences) requires emergency decompressive laparotomy 4
• Bacterial translocation and systemic infections due to intestinal bacterial overgrowth 4
• Severe fluid sequestration leading to systemic hypovolemia 4

Common Pitfalls and Caveats

1. Failure to distinguish between functional and mechanical ileus - Always rule out mechanical obstruction before treating as functional ileus
2. Overuse of opioids - These worsen ileus and should be minimized or avoided
3. Excessive fluid administration - Can worsen bowel edema and prolong ileus
4. Delayed mobilization - Early mobilization is critical for recovery
5. Overlooking electrolyte abnormalities - Regular monitoring and correction is essential

By following this comprehensive approach to ileus management, focusing on decompression, fluid management, pain control, early nutrition, and mobilization, most cases will resolve without the need for surgical intervention.