Treatment of Ileus
The treatment of ileus requires a structured approach prioritizing fluid resuscitation, nasogastric decompression when indicated, early mobilization, opioid-sparing analgesia, and avoidance of routine interventions that prolong recovery. 1, 2
Initial Resuscitation and Stabilization
Administer isotonic intravenous fluids (lactated Ringer's or normal saline) immediately to correct dehydration and electrolyte imbalances, continuing until vital signs normalize and the patient shows no evidence of ongoing ileus 1, 3. Target weight gain of less than 3 kg by postoperative day three to prevent intestinal edema that worsens ileus 4, 2.
Correct electrolyte abnormalities aggressively, particularly potassium and magnesium deficiencies, as these directly impair intestinal motility 2, 3.
Place a nasogastric tube only if the patient has severe abdominal distention, active vomiting, or aspiration risk—not routinely 1, 2. Remove the tube as early as possible, as prolonged nasogastric decompression extends ileus duration 4, 2.
Pain Management Strategy
Implement mid-thoracic epidural analgesia with local anesthetics as the first-line analgesic approach, as this is highly effective at preventing and treating ileus compared to systemic opioids 1, 2. This represents the single most important modifiable factor in ileus management 3.
Minimize or eliminate opioid analgesics whenever possible, as they directly prolong gastrointestinal dysmotility 1, 3. If systemic opioids are necessary, use the lowest effective dose 2.
Avoid anticholinergic medications entirely, as they worsen ileus 2, 3.
Early Mobilization and Nutrition
Begin mobilization immediately once the patient's condition allows, as early ambulation stimulates bowel function and prevents complications of immobility 4, 2. Remove urinary catheters early to facilitate mobilization 2.
Encourage early oral intake with small portions once bowel sounds return, particularly after right-sided resections and small-bowel anastomoses 4, 2. Start with clear liquids and advance as tolerated 1, 3.
Initiate tube feeding within 24 hours if oral intake will be inadequate (less than 50% of caloric requirements) for more than 7 days 4, 2.
Provide early parenteral nutrition if enteral feeding is contraindicated due to intestinal obstruction, sepsis, intestinal ischemia, high-output fistulae, or severe gastrointestinal hemorrhage 4, 2.
Pharmacologic Interventions
Administer oral laxatives (bisacodyl 10-15 mg daily to three times daily and magnesium oxide) once oral intake resumes to promote bowel function 1, 2.
Consider alvimopan (a μ-opioid receptor antagonist) to accelerate gastrointestinal recovery specifically when opioid analgesia is being used 1.
Use chewing gum as an adjunctive measure, as it provides cephalic-vagal stimulation that can shorten ileus duration 1, 3.
For persistent ileus unresponsive to initial measures, consider water-soluble contrast agents or neostigmine as rescue therapy 4, 2.
Special Clinical Scenarios
For ileus associated with Clostridium difficile infection, administer specific antimicrobial therapy; use parenteral metronidazole when oral administration is not possible 1, 3.
In neutropenic enterocolitis with ileus, provide broad-spectrum antibiotics covering enteric gram-negative organisms, gram-positive organisms, and anaerobes, while strictly avoiding anticholinergics, antidiarrheals, and opioids 1.
For bacterial overgrowth contributing to ileus, consider antibiotics such as rifaximin, amoxicillin-clavulanic acid, metronidazole, or ciprofloxacin 2.
Monitoring Parameters
Monitor for return of bowel function by assessing for passage of flatus and presence of bowel sounds 3. These clinical markers guide advancement of oral intake and discontinuation of supportive measures.
Maintain thromboembolism prophylaxis with subcutaneous heparin in patients with prolonged immobility 3.
Critical Pitfalls to Avoid
Do not routinely use nasogastric tubes, as they may prolong ileus duration rather than shorten it 4, 2.
Avoid fluid overloading, which impairs gastrointestinal function and worsens intestinal edema 4, 2, 3.
Do not delay mobilization or oral intake based solely on absence of bowel sounds, as early feeding maintains intestinal function even in the presence of ileus 4.
Recognize that metoclopramide, erythromycin, beta blockers, naloxone, and routine neostigmine are not effective for standard ileus treatment and should not be used routinely 5.