What is the initial treatment for paralytic ileus?

Initial Treatment for Paralytic Ileus

The initial treatment for paralytic ileus should focus on bowel rest, nasogastric tube decompression, intravenous fluid resuscitation, and correction of underlying electrolyte abnormalities while avoiding medications that further impair bowel motility. 1

Immediate Management Steps

• Maintain nil per os (NPO) status until bowel function returns, as oral intake is not suitable during paralytic ileus due to impaired gastric emptying and intestinal transit 1
• Place a nasogastric tube for decompression to relieve abdominal distension and prevent aspiration 2
• Provide adequate intravenous fluid resuscitation to correct fluid and electrolyte imbalances 1, 2
• Discontinue or minimize medications that can worsen ileus, particularly opioids 1
• Monitor for signs of complications such as bowel perforation or ischemia 3, 4

Pharmacological Management

• Avoid antidiarrheal medications such as loperamide and diphenoxylate, which can worsen ileus 1
• Consider prokinetic agents such as metoclopramide (10-20 mg PO four times daily) for stimulating gastrointestinal motility 5, 2
• For persistent cases, neostigmine may be considered as it has shown efficacy in treating paralytic ileus 2, 4
• If bacterial overgrowth is suspected in prolonged ileus, antibiotics may be needed (options include rifaximin, metronidazole, or amoxicillin-clavulanic acid) 1

Nutritional Support

• If oral intake is inadequate for more than 7 days, consider enteral nutrition via feeding tube or parenteral nutrition 1, 2
• When reintroducing oral feeding, start with clear liquids and progress to small, frequent meals with low-fat, low-fiber content 1
• Enteral nutrition is preferred over parenteral nutrition when the gut is accessible and functioning, as it helps maintain the gut mucosal barrier and reduce bacterial translocation 1

Supportive Measures

• Encourage early mobilization as soon as the patient's condition allows to stimulate bowel motility 1, 2
• Optimize fluid management by avoiding overhydration, aiming for weight gain <3 kg 2
• Consider thoracic epidural analgesia for pain management in postoperative ileus, as it has been associated with reduced incidence of paralytic ileus and improved intestinal blood flow 1

Monitoring and Follow-up

• Assess for return of bowel sounds, passage of flatus, and bowel movements 2, 3
• Monitor abdominal distension, pain, and radiographic findings 3
• Reassess the effectiveness of therapy daily and adjust management accordingly 2

Common Pitfalls to Avoid

• Delaying nasogastric decompression, which can lead to increased abdominal distension and risk of aspiration 3
• Continuing opioid medications, which exacerbate ileus 1
• Premature initiation of oral intake before return of bowel function 2
• Failing to identify and treat underlying causes of ileus (e.g., electrolyte abnormalities, medications, infections) 6, 3