What is the management of gastric ileus?

Management of Gastric Ileus

The management of gastric ileus requires a multifaceted approach including fluid resuscitation, nasogastric decompression, correction of electrolyte abnormalities, early mobilization, and pharmacologic interventions when appropriate. 1

Initial Assessment and Management

• Administer isotonic intravenous fluids to correct dehydration and electrolyte imbalances, particularly potassium and magnesium, which can affect intestinal motility 1
• 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, which can significantly affect intestinal motility 1
• Administer subcutaneous heparin to reduce the risk of thromboembolism in patients with prolonged immobility 1

Pharmacologic Interventions

• Consider metoclopramide (10 mg IV slowly over 1-2 minutes) to stimulate gastric emptying, especially in diabetic gastroparesis 2
• For patients with renal impairment (creatinine clearance below 40 mL/min), reduce the initial metoclopramide dose by approximately half 2
• Avoid medications that can worsen ileus, such as anticholinergics and opioids 1
• Consider alvimopan to accelerate gastrointestinal recovery when opioid analgesia is necessary 1
• Oral magnesium oxide may promote bowel function once oral intake is resumed 1

Supportive Care

• Encourage early mobilization as soon as the patient's condition allows to help stimulate bowel function 1
• Avoid fluid overloading as it can worsen intestinal edema and prolong ileus 1, 3
• Consider nutritional support if ileus is prolonged, with enteral nutrition preferred when possible 1
• Remove nasogastric tubes as early as possible, as routine nasogastric decompression may prolong ileus 1
• Consider chewing gum to help stimulate bowel function through cephalic-vagal stimulation 1

Special Considerations for Postoperative Ileus

• Implement opioid-sparing analgesia strategies, such as ketorolac, to minimize narcotic use 1, 4
• Consider mid-thoracic epidural analgesia to prevent postoperative ileus 1
• Prefer laparoscopic over open surgical approaches when surgery is necessary to reduce the risk of postoperative ileus 1, 5
• For patients with diabetic gastroparesis, metoclopramide may be administered for up to 10 days until symptoms subside 2, 6
• In cases of persistent gastric atony not responding to medical management, surgical options such as near-total gastrectomy may be considered for severe cases 7

Monitoring and Follow-up

• Monitor for signs of bowel function return, including passage of flatus and bowel sounds 1
• Resume oral intake gradually once bowel function returns, starting with clear liquids and advancing as tolerated 1
• For persistent ileus with abdominal distention, consider CT imaging to rule out mechanical obstruction or other complications 8
• Monitor intra-abdominal pressure in critically ill patients, as intra-abdominal hypertension has been found in up to 20% of critically ill patients and may lead to multiple organ dysfunction 3

Management of Complications

• For abdominal compartment syndrome (IAP above 20-25 mmHg with systemic consequences), decompressive laparotomy with temporary abdominal closure is the therapy of choice 3
• If ileus is associated with peritonitis due to perforation, immediate surgical exploration is recommended in unstable patients 9, 8
• For stable patients with perforation less than 1 cm, laparoscopic primary repair with omental patch is recommended 9, 8
• Consider placement of a gastrostomy tube proximal to the perforation site if significant postoperative ileus is anticipated due to peritonitis 9