How to manage a case of paralytic ileus?

Management of Paralytic Ileus

Immediately initiate NPO status, nasogastric decompression, aggressive IV fluid resuscitation with electrolyte correction, and discontinue all opioids—these four interventions form the cornerstone of paralytic ileus management and should be implemented simultaneously. 1

Immediate Initial Management

Bowel Rest and Decompression

• Maintain strict NPO status until bowel function returns, as oral intake worsens gastric emptying and intestinal transit during paralytic ileus 1
• Place a nasogastric tube for gastric decompression to relieve abdominal distension and prevent aspiration of gastric contents 1
• Monitor for return of bowel sounds, passage of flatus, and bowel movements as markers of resolution 1

Fluid and Electrolyte Management

• Provide aggressive intravenous fluid resuscitation to correct hypovolemia and electrolyte imbalances, which are critical contributors to ileus 1
• Avoid fluid overload—aim for perioperative weight gain less than 2.5-3 kg, as excessive fluid administration worsens bowel edema and prolongs ileus 2, 1
• Correct electrolyte abnormalities, particularly hypokalemia and hypomagnesemia, which directly impair intestinal smooth muscle function 3

Medication Review

• Immediately discontinue or minimize opioid analgesics, as they are the most common pharmacologic cause of worsening ileus 1, 4
• Avoid antidiarrheal medications (loperamide, diphenoxylate) which further suppress bowel motility 1
• Review all medications and stop any agents that decrease gastrointestinal motility 3

Pharmacological Interventions

Prokinetic Agents

• Consider metoclopramide (10-20 mg PO/IV four times daily) to stimulate gastric and small bowel motility 1, 5
• Neostigmine (2-2.5 mg IV slowly over 3-5 minutes) should be considered for persistent paralytic ileus, particularly colonic pseudo-obstruction, with continuous cardiac monitoring due to risk of bradycardia 1, 6, 3

Laxatives for Bowel Stimulation

• Administer bisacodyl and magnesium oxide to stimulate colonic motility once small bowel function begins returning 5
• Consider lactulose or polyethylene glycol solutions for small bowel ileus when initial conservative measures fail 3

Antibiotics for Bacterial Overgrowth

• Use rifaximin, metronidazole, or amoxicillin-clavulanic acid if bacterial overgrowth is suspected in prolonged ileus (typically after 7+ days) 1, 7

Supportive Measures

Early Mobilization

• Encourage early and frequent patient mobilization as soon as medically stable, as ambulation stimulates the migrating motor complex and bowel motility 1, 5, 4
• This is particularly important in orthopedic and postoperative patients where immobility contributes significantly to ileus development 4

Pain Management

• Consider thoracic epidural analgesia for postoperative pain control as an opioid-sparing strategy 1
• Use multimodal analgesia with NSAIDs and acetaminophen when possible 4

Nutritional Support

Timing and Route

• If oral intake remains inadequate for more than 7 days, initiate enteral nutrition via feeding tube or parenteral nutrition 1, 5
• Prefer enteral nutrition over parenteral nutrition when the gut is accessible, as it maintains intestinal barrier function 1

Reintroduction of Oral Feeding

• Do not initiate oral intake prematurely—wait for objective evidence of bowel function return (bowel sounds, flatus, bowel movement) 1
• Start with clear liquids and progress to small, frequent meals with low-fat, low-fiber content 1
• Separate liquids from solids by avoiding drinking 15 minutes before or 30 minutes after eating 7

Monitoring and Reassessment

• Assess daily for return of bowel function: presence of bowel sounds, passage of flatus, and bowel movements 1
• Reassess treatment effectiveness daily and adjust management accordingly 1, 5
• Monitor for complications including bowel perforation, aspiration, malnutrition, and sepsis 4, 8

Critical Pitfalls to Avoid

• Never continue opioid medications—they are the single most modifiable factor exacerbating ileus 1, 4
• Avoid premature oral intake before documented return of bowel function, as this leads to vomiting and aspiration risk 1
• Do not overhydrate patients—excessive IV fluids worsen bowel wall edema and prolong ileus 2, 1
• Do not delay nasogastric decompression in patients with significant distension or vomiting, as this increases aspiration risk 1

When Conservative Management Fails

• Consider water-soluble contrast agents for diagnostic and potentially therapeutic benefit in persistent postoperative ileus 5
• Endoscopic decompression or cecostomy may be necessary for colonic pseudo-obstruction when cecal diameter approaches 12 cm and perforation risk is high 3
• Surgical intervention is reserved for cases with suspected mechanical obstruction, bowel ischemia, or perforation 8, 9