What is the management approach for ileus?

Management of Ileus

The management of ileus should focus on correcting fluid and electrolyte imbalances, avoiding medications that worsen motility, implementing early mobilization, and providing appropriate nutritional support while the bowel recovers. 1, 2

Initial Assessment and Management

• Administer isotonic intravenous fluids (such as normal saline) to correct dehydration and electrolyte imbalances 1, 2
• Place a nasogastric tube for decompression in patients with severe abdominal distention, vomiting, or risk of aspiration 1
• Maintain nil per os (NPO) status initially until bowel function returns 1
• Correct electrolyte abnormalities, particularly potassium and magnesium, which can affect intestinal motility 1, 3
• Administer subcutaneous heparin to reduce the risk of thromboembolism in patients with prolonged immobility 1
• Exclude other causes of ileus such as intra-abdominal sepsis, partial obstruction, enteritis, or medication effects 3

Pharmacologic Interventions

• Consider alvimopan (a μ-opioid receptor antagonist) to accelerate gastrointestinal recovery when opioid analgesia is necessary 1, 2
• Avoid medications that can worsen ileus, such as anticholinergics and opioids 1
• Implement opioid-sparing analgesia strategies for postoperative ileus 1
• Consider mid-thoracic epidural analgesia to prevent postoperative ileus 3, 1, 2
• Oral magnesium oxide may promote bowel function once oral intake is resumed 3, 1, 2
• Bisacodyl (10 mg orally twice daily) can improve postoperative intestinal function 3
• Metoclopramide is not FDA-approved specifically for ileus but may be used to stimulate gastric emptying and intestinal transit 4

Supportive Care

• Encourage early mobilization to help stimulate bowel function and prevent complications of prolonged bed rest 1, 2
• Avoid fluid overloading as it can worsen intestinal edema and prolong ileus 3, 1, 2
• Consider chewing gum to help stimulate bowel function through cephalic-vagal stimulation 3, 1, 2
• Remove nasogastric tubes as early as possible as routine nasogastric decompression may prolong ileus 1, 2
• Monitor for signs of bowel function return, including passage of flatus and bowel sounds 1

Nutritional Support

• Provide nutritional support if ileus is prolonged, with enteral nutrition preferred when possible 1
• Resume oral intake gradually once bowel function returns, starting with clear liquids and advancing as tolerated 1, 2
• If oral intake is inadequate (<50% of caloric requirement) for more than 7 days, consider tube feeding or parenteral nutrition 5

Special Considerations for Postoperative Ileus

• Prefer laparoscopic over open surgical approaches when surgery is necessary 3, 1, 2
• Avoid nasogastric decompression as it may increase the duration of postoperative ileus 3, 2
• For high-output jejunostomy/ileostomy, restrict oral hypotonic fluids to 500 ml/day and provide glucose/saline solution with sodium concentration of at least 90 mmol/l 3
• Consider loperamide (2-8 mg) before food to reduce motility in patients with high-output stomas 3

Management of Specific Types of Ileus

• For ileus associated with Clostridium difficile infection, administer appropriate antimicrobial therapy 1, 2
• For neutropenic enterocolitis with ileus, use broad-spectrum antibiotics covering enteric gram-negative organisms, gram-positive organisms, and anaerobes 2
• For mechanical ileus, surgical intervention may be necessary if complete obstruction or strangulation is suspected 6, 7

Prevention Strategies

• Minimize opioid use for pain control 1, 8
• Maintain proper fluid balance without overload 1, 2
• Early removal of urinary catheters to facilitate mobilization 3
• Avoid routine use of nasogastric tubes 3, 1

By following this comprehensive approach to ileus management, focusing on correcting underlying causes, providing supportive care, and implementing appropriate pharmacologic interventions, most cases of ileus can be effectively managed with improved patient outcomes.