Hypokalemic Ileus: Definition and Management

Ileus secondary to hypokalemia is called paralytic ileus. 1

Pathophysiology of Hypokalemic Paralytic Ileus

Hypokalemia can lead to impaired intestinal motility, resulting in partial or complete blockage of the small and/or large intestine without mechanical obstruction 2
Low potassium levels affect smooth muscle function in the gastrointestinal tract, leading to decreased contractility and peristalsis 1
Paralytic ileus presents with signs and symptoms of intestinal obstruction without mechanical lesions in the intestinal lumen 3
Severe hypokalemia can cause flaccid paralysis of intestinal muscles, leading to functional bowel obstruction 4

Diuretic therapy (loop and thiazide diuretics) is a common cause of hypokalemia that can lead to paralytic ileus 4
Gastrointestinal losses through vomiting, diarrhea, or high-output stomas/fistulas 5
Secondary hyperaldosteronism due to sodium depletion, which increases urinary potassium excretion 5
Hypomagnesemia, which causes dysfunction of potassium transport systems and increases renal potassium excretion 5
Renal tubular disorders such as Gitelman's syndrome and Bartter syndrome can cause chronic hypokalemia leading to recurrent paralytic ileus 6, 5

Abdominal distension, colicky abdominal pain, nausea, and vomiting 5
Absence of bowel sounds on auscultation 2
Severe constipation with difficulty in the passage of both gas and feces 3
Dilated intestinal loops visible on imaging studies 2
Systemic consequences may include hypovolemia, bacterial overgrowth, and systemic inflammatory response syndrome 2

Correct hypokalemia by addressing the underlying cause and replacing potassium 1
Oral replacement is preferred except when there is no functioning bowel or in the presence of severe symptoms 1
Intravenous potassium replacement may be necessary in severe cases or when oral intake is not possible 4
Maintain adequate hydration status and avoid drugs known to impair intestinal perfusion 2

Correct hypomagnesemia if present, as potassium replacement may be ineffective until magnesium is corrected 4
In patients with sodium depletion and secondary hyperaldosteronism, sodium replacement is essential to correct the underlying cause of hypokalemia 5
For patients with high-output stomas or fistulas, sodium chloride supplementation and fluid restriction may be necessary 5

Regular monitoring of serum potassium in high-risk patients 4
Consider potassium-sparing diuretics in patients requiring long-term diuretic therapy 4
Dietary counseling to increase potassium intake when appropriate 4

In patients with chronic kidney disease, colonic potassium excretion can be up to 3 times greater than in individuals with normal renal function, placing them at higher risk for hypokalemia 7
Hypokalemia due to renal potassium wasting may require potassium-sparing diuretics in addition to potassium replacement 1
Serum potassium concentration is an inaccurate marker of total-body potassium deficit; mild hypokalemia may be associated with significant total-body potassium deficits 1

Intestinal dilatation, increased luminal pressure, and gut wall ischemia 2
Increased intra-abdominal pressure leading to abdominal compartment syndrome 2
Multiple organ dysfunction affecting cardiovascular, hepatic, pulmonary, renal, and neurological function 2
Bacterial translocation and systemic invasive infections 2