What is the treatment for colonic ileus?

Treatment of Colonic Ileus

The treatment of colonic ileus requires a combination of supportive measures including intravenous fluid and electrolyte replacement, discontinuation of medications that inhibit intestinal motility, and correction of underlying causes. 1

Initial Management

• Intravenous fluid and electrolyte replacement to correct and prevent dehydration and electrolyte imbalance, with particular attention to potassium supplementation (at least 60 mmol/day) as hypokalaemia can promote toxic dilatation 2
• Daily physical examination to evaluate abdominal tenderness and rebound tenderness, with joint medical and surgical management 2
• Close monitoring with recording of vital signs four times daily, stool chart documentation, and measurement of laboratory parameters (FBC, CRP, serum electrolytes, albumin, and liver function tests) every 24-48 hours 2
• Daily abdominal radiography if colonic dilatation is detected (transverse colon diameter >5.5 cm) 2
• Withdrawal of anticholinergic, anti-diarrhoeal, non-steroidal anti-inflammatory, and opioid medications that may worsen ileus 2
• Subcutaneous prophylactic low-molecular-weight heparin to reduce the risk of thromboembolism, which is increased during immobility and inflammatory states 2

Specific Interventions

• For proximal constipation contributing to ileus, administer stool bulking agents or laxatives 2
• In cases of distal fecal impaction, perform digital fragmentation and extraction of stool as first-line intervention 3
• For pharmacologic treatment of colonic pseudo-obstruction, neostigmine (0.4-0.8 mg/h as continuous intravenous infusion over 24 hours) has shown efficacy in promoting defecation in 79% of patients with critical illness-related colonic ileus 4
• Early enteral nutrition should be implemented as it facilitates return of normal bowel function, achieving nutritional goals, and reducing hospital length of stay 5

Special Considerations

• If colonic dilatation exceeds 12 cm in the cecum and does not respond to conservative measures, decompressive procedures (colonoscopic decompression or surgical intervention) may be indicated 6
• Nutritional support (enteral preferred over parenteral) should be provided if the patient is malnourished, as enteral nutrition is associated with fewer complications than parenteral nutrition (9% vs 35%) 2
• For patients with severe colonic distention not responding to conservative measures, colonoscopic decompression may be necessary 1

Monitoring and Follow-up

• Continuous assessment of abdominal distention, bowel sounds, and passage of flatus or stool to evaluate response to treatment 2
• Regular radiographic assessment to monitor colonic dilatation 2
• Close collaboration between gastroenterologists and surgeons to determine if surgical intervention becomes necessary 2

Cautions and Pitfalls

• Failure to correct electrolyte abnormalities, particularly hypokalemia or hypomagnesemia, can worsen ileus and promote toxic dilatation 2
• Delayed recognition of mechanical obstruction masquerading as functional ileus can lead to bowel ischemia and perforation 7
• Neostigmine should be used with caution as it may cause bradycardia and increased bronchial secretions; continuous cardiac monitoring is recommended during administration 4