What are the management options for mild ileus (inflammation of the ileum)?

Management of Mild Ileus

For mild ileus (functional/paralytic), initiate conservative management with bowel rest (NPO status), intravenous fluid resuscitation, nasogastric decompression, electrolyte correction, and discontinuation of medications impairing gut motility—this approach resolves obstruction in approximately 73% of cases within 22 hours to 5 days. 1, 2

Initial Assessment and Diagnosis

Distinguish between functional (paralytic) and mechanical ileus immediately, as this determines your entire management strategy 3, 4:

• Obtain complete blood count, electrolytes, BUN/creatinine, and lactate to assess for dehydration, metabolic abnormalities, and potential bowel ischemia 1
• Perform abdominal CT scan to rule out mechanical obstruction and evaluate for complications like perforation or strangulation 1, 3
• Monitor for peritoneal signs (guarding, rebound tenderness) which indicate surgical emergency 4

Conservative Management (First-Line for Mild Ileus)

Implement the following supportive measures simultaneously 1, 5:

• Strict NPO status with bowel rest 1
• Nasogastric tube placement for gastric decompression to prevent aspiration and reduce intestinal distension 1, 4
• Aggressive IV fluid resuscitation to correct hypovolemia from third-spacing (ileus causes significant abdominal fluid sequestration) 1, 5
• Correct all electrolyte abnormalities, particularly potassium, magnesium, and calcium, as these directly impair bowel motility 1
• Discontinue all medications that worsen dysmotility: opioids, anticholinergics, and sedatives 1, 6

Monitoring Strategy

Perform serial abdominal examinations every 4-6 hours to detect clinical deterioration 1:

• Watch for worsening abdominal pain, progressive distension, fever, tachycardia, or peritoneal signs—these indicate potential perforation or strangulation requiring immediate surgery 1, 5
• Obtain serial abdominal radiographs to monitor bowel gas patterns and colonic diameter 1
• Measure intra-abdominal pressure if distension is severe (>20-25 mmHg indicates abdominal compartment syndrome requiring urgent decompression) 5

Duration of Conservative Trial

Continue conservative management for up to 5 days maximum 2:

• Most cases that will resolve do so within 22 hours to 5 days 2
• If no improvement after 5 days, conservative therapy is ineffective and surgery should be considered 2
• Do not delay surgery beyond 5 days in complete obstruction, as this increases morbidity without improving outcomes 4, 2

When to Abandon Conservative Management

Proceed immediately to surgery if any of the following develop 1, 4:

• Signs of peritonitis (guarding, rebound tenderness, rigidity) 1
• Evidence of perforation (free air on imaging, acute abdomen) 1
• Clinical deterioration (worsening pain, progressive leukocytosis, fever, hemodynamic instability) 1, 4
• Strangulation suspected (severe continuous pain, bloody stools, metabolic acidosis) 4
• Abdominal compartment syndrome (IAP >20-25 mmHg with organ dysfunction) 5

Adjunctive Measures

Consider prokinetic agents cautiously 6:

• Metoclopramide may be used but avoid in suspected mechanical obstruction or recent bowel anastomosis (theoretical risk of increased pressure on suture lines) 6
• Early mobilization once clinically appropriate to stimulate bowel function 7

Critical Pitfalls to Avoid

• Do not confuse mild functional ileus with early mechanical obstruction—CT imaging is essential to differentiate 3
• Do not continue conservative management beyond 5 days if no improvement, as this increases complications without benefit 2
• Do not miss abdominal compartment syndrome in patients with severe distension—measure bladder pressure if IAP elevation suspected 5
• Do not overlook electrolyte correction—hypokalemia and hypomagnesemia directly impair gut motility and prevent resolution 1

Recovery and Advancement

Once bowel function returns (passage of flatus, decreased distension, return of bowel sounds) 1:

• Gradually advance diet from clear liquids to regular diet as tolerated 1
• Remove nasogastric tube when output decreases and patient tolerates oral intake 1
• Discontinue IV fluids once adequate oral intake established 1