What is the management of ileus?

Management of Ileus

The management of ileus should focus on bowel decompression, fluid resuscitation, electrolyte correction, early mobilization, and avoidance of opioids, with thoracic epidural analgesia being the optimal approach for pain control. 1

Initial Assessment and Management

Decompression

• Nasogastric tube placement for gastric decompression to relieve pressure and prevent vomiting
• Consider venting gastrostomy in severe cases that don't respond to conservative management 1
• Avoid routine nasogastric decompression when possible, as its avoidance may reduce the duration of postoperative ileus 2

Fluid and Electrolyte Management

• Administer isotonic IV fluids (lactated Ringer's or normal saline) based on degree of dehydration 1
• Initial fluid bolus of 20 mL/kg for patients with tachycardia and potential sepsis 1
• Avoid fluid overload as excessive IV fluids can worsen ileus 1
• Monitor and correct electrolyte imbalances, particularly potassium, magnesium, and phosphate

Pain Management

• Thoracic epidural analgesia is the optimal approach for pain control in ileus as it effectively prevents and treats postoperative ileus while providing superior analgesia compared to opioid-based regimens 1
• Use low-dose concentrations of local anesthetic combined with short-acting opiates for effective pain control 1
• Acetaminophen/Paracetamol (1g IV every 6 hours) as an adjunct to decrease pain intensity and reduce opioid requirements 1
• Nefopam (20mg IV) is recommended as an opioid-sparing agent with no detrimental effects on intestinal motility 1

Nutritional Support

• Administer nutritional support (parenteral or enteral, according to GI function) in patients as soon as possible 2
• For patients who can tolerate oral intake, consider liquid feeds as gastric motility may be less deranged for liquids than solids 1
• Implement frequent small meals with low-fat, low-fiber content 1
• Early removal of nasogastric tubes and early oral feeding as soon as the patient is lucid 1
• Enteral nutrition is preferred over parenteral nutrition when possible 1

Pharmacological Interventions

• Consider prokinetic agents:
  • Metoclopramide to stimulate upper GI motility
  • Erythromycin as a motilin receptor agonist
• For bacterial overgrowth causing diarrhea, consider Rifaximin or alternating courses of antibiotics 1
• Oral magnesium oxide may promote postoperative bowel function, though evidence is mixed 2
• Bisacodyl (10 mg, p.o. twice daily) may improve postoperative intestinal function 2

Mobilization

• Early and regular mobilization to stimulate bowel function 1
• Avoid drainage systems that significantly impair independent mobilization 2

Thromboprophylaxis

• Administer venous thromboembolism prophylaxis with LMWH due to the high risk of thrombotic events 2

Monitoring and Complications

• Monitor vital signs every 4 hours
• Daily abdominal examinations to assess for return of bowel sounds, reduction in abdominal distention, and passage of flatus or stool 1
• Be vigilant for intra-abdominal hypertension, which is found in up to 20% of critically ill patients and can lead to multiple organ dysfunction 3
• Monitor for abdominal compartment syndrome (IAP above 20-25 mmHg with systemic consequences), which requires decompressive laparotomy 3

Special Considerations

Postoperative Ileus

• Typically resolves spontaneously after 2-3 days 4
• Primarily reflects inhibition of colonic motility 4

Paralytic Ileus

• More severe, lasts more than 3 days 4
• Represents inhibition of small bowel activity 4
• May require more aggressive intervention

Surgical Intervention

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

Pitfalls and Caveats

• Distinguish between mechanical and functional ileus, as treatment approaches differ 5
• Avoid opioid analgesics when possible as they can worsen ileus
• Don't overlook electrolyte imbalances, which can exacerbate ileus
• Avoid fluid overload, which can worsen intestinal edema and prolong ileus
• Be aware that postoperative ileus follows any operation but is worse when the peritoneum is entered 4