What is the management of paralytic (adynamic) ileus?

Management of Paralytic (Adynamic) Ileus

The management of paralytic ileus should focus on bowel rest, nasogastric decompression, intravenous fluid resuscitation, electrolyte correction, and addressing the underlying cause, while avoiding enemas which are contraindicated in bowel obstruction. 1, 2

Definition and Pathophysiology

• Paralytic ileus is characterized by the cessation of bowel motility without a mechanical obstruction, resulting in functional obstruction of the intestine 3, 4
• It commonly occurs following surgery, traumatic injury, electrolyte imbalances, medications (especially opioids), or as a complication of various medical conditions 3, 4

Initial Assessment

• Complete history, physical examination, and laboratory tests should be performed to identify the underlying cause 1
• Evaluate for recent surgery, medication use (especially opioids), electrolyte abnormalities, and signs of infection 1, 4
• Abdominal X-ray and/or CT scan should be obtained to confirm the diagnosis and rule out mechanical obstruction 1, 2

Management Algorithm

Step 1: Supportive Care

• Bowel rest: Nothing by mouth until bowel function returns 1, 4
• Nasogastric tube decompression to relieve abdominal distension and prevent vomiting 1, 2
• Intravenous fluid resuscitation to correct dehydration and maintain fluid balance 1, 4
• Electrolyte correction, particularly potassium, magnesium, and phosphate abnormalities 1, 4

Step 2: Address Underlying Cause

• Discontinue or minimize medications that decrease bowel motility, especially opioids 3, 4
• Treat any underlying infection or inflammation 1
• Correct electrolyte imbalances that may contribute to decreased bowel motility 1, 4

Step 3: Pharmacologic Interventions

• Prokinetic agents may be considered once adequate hydration is established:
  • Metoclopramide 10-20 mg PO/IV QID can be used as a prokinetic agent to stimulate bowel motility 1, 5
  • Caution: Monitor for extrapyramidal symptoms with metoclopramide, especially in younger patients and with prolonged use 5
• Avoid antimotility drugs (e.g., loperamide) as they can worsen ileus 1

Step 4: Nutritional Support

• Consider parenteral nutrition if ileus persists beyond 5-7 days 1, 4
• Resume oral feeding gradually once bowel sounds return and flatus or bowel movements occur 1

Special Considerations

Postoperative Ileus

• Early mobilization of the patient is crucial to stimulate bowel motility 3, 4
• Thoracic epidural analgesia may reduce the incidence of postoperative ileus by attenuating the surgical stress response and reducing opioid use 1
• Multimodal pain management strategies to minimize opioid use 1, 3

Contraindicated Interventions

• Enemas are absolutely contraindicated in patients with paralytic ileus as they can increase the risk of perforation and worsen the clinical status 2
• Antimotility drugs should be avoided as they can prolong the duration of ileus 1

Monitoring and Follow-up

• Regular assessment of abdominal distension, bowel sounds, and passage of flatus or stool 1, 4
• Monitor for complications such as aspiration, malnutrition, and prolonged hospital stay 3, 6
• If ileus persists despite conservative management, consider additional imaging to rule out complications or missed mechanical obstruction 1, 4

Complications of Untreated Paralytic Ileus

• Abdominal pain and distension 3, 4
• Malnutrition and electrolyte imbalances 4, 6
• Bacterial translocation and sepsis 6
• Bowel ischemia or perforation in severe cases 4, 6

When to Consider Surgical Intervention

• Failure to respond to conservative management after 72 hours 1, 4
• Signs of bowel ischemia or perforation 4, 6
• Uncertainty about the diagnosis (to rule out mechanical obstruction) 1, 4