Treatment for Ileus
The primary treatment for ileus includes intravenous fluid resuscitation, bowel rest, and correction of underlying causes, while avoiding medications that decrease gut motility. 1, 2
Initial Management
- Isotonic intravenous fluids (lactated Ringer's or normal saline) should be administered when ileus is present, as this is a strong recommendation with moderate evidence 1
- Nasogastric tube placement may be necessary in patients with severe abdominal distention, vomiting, or risk of aspiration 1, 3
- Intravenous rehydration should be continued until pulse, perfusion, and mental status normalize, and the patient has no evidence of ileus 1
- Discontinue medications that can worsen ileus, particularly opioids and anticholinergics 4
- Correct electrolyte abnormalities, particularly potassium, magnesium, and calcium, which can contribute to decreased gut motility 2, 3
Supportive Care
- Once rehydration is complete, maintenance fluids should be administered until bowel function returns 1
- Early mobilization of the patient should be encouraged as it can help stimulate bowel function 4
- Monitor for signs of abdominal compartment syndrome (increased intra-abdominal pressure with systemic consequences), which may require surgical intervention 3
- Nutritional support may be necessary if ileus is prolonged, with parenteral nutrition considered in cases of prolonged ileus 1, 3
Pharmacologic Interventions
- Metoclopramide may be used to stimulate gastric emptying and intestinal transit in cases of ileus 5
- Neostigmine (2 mg IV) can be considered for pharmacologic decompression in cases of severe colonic pseudo-obstruction (Ogilvie's syndrome) when conservative measures fail 6
- Alvimopan (a μ-opioid receptor antagonist) can accelerate gastrointestinal recovery in postoperative ileus when opioid analgesia is being used 1
- Chewing gum has been shown to have a positive effect on postoperative ileus duration and can be recommended 1
- Oral magnesium oxide may promote bowel function in postoperative ileus 1
Prevention of Postoperative Ileus
- Mid-thoracic epidural analgesia is highly effective at preventing postoperative ileus compared to intravenous opioid analgesia 1
- Laparoscopic surgical approaches lead to faster return of bowel function compared to open surgery 1
- Avoid fluid overloading during and after surgery as it impairs gastrointestinal function 1
- Avoid routine nasogastric decompression as it may prolong the duration of ileus 1
Special Considerations
- In cases of ileus associated with Clostridium difficile infection, specific antimicrobial therapy is required, and parenteral metronidazole can be used when oral administration is not possible 1
- For ileus in neutropenic enterocolitis, broad-spectrum antibiotics covering enteric gram-negative organisms, gram-positive organisms, and anaerobes should be administered 1
- Anticholinergic, antidiarrheal, and opioid agents should be avoided in neutropenic enterocolitis as they may aggravate ileus 1
- Surgical intervention may be necessary in cases of mechanical obstruction, bowel ischemia, or perforation 7
Monitoring and Follow-up
- Regular assessment of abdominal distention, bowel sounds, and passage of flatus or stool 3, 4
- Monitor for signs of clinical deterioration including increased abdominal pain, fever, or hemodynamic instability 3
- Resume oral intake gradually once bowel function returns, starting with clear liquids and advancing as tolerated 1, 4